Provider Demographics
NPI:1518959741
Name:TARGETED MOLECULAR DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:TARGETED MOLECULAR DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RESNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-789-1233
Mailing Address - Street 1:610 OAKMONT LN
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-789-1233
Mailing Address - Fax:630-789-3765
Practice Address - Street 1:610 OAKMONT LN
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-5548
Practice Address - Country:US
Practice Address - Phone:630-789-1233
Practice Address - Fax:630-789-3765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid